No abstract available.http://bjsm.bmj.com/hb201

Makdissi, Michael

Patricios, Jonathan Speridon

UPSpace at the University of Pretoria

The sports concussion picture: fewer ‘pixels’, more HD Jon S Patricios,1,2 Michael Makdissi3 1Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, Johannesburg, South Africa; 2Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 3The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia Correspondence to Dr Jon S Patricios, Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, Johannesburg, P.O. Box 1267, Parklands 2121, South Africa; jpat@mweb.co.za  “The only ones who see the whole picture, are the ones who step out of the frame” Salman Rushdie, The Ground Beneath Her Feet CURRENT CONCUSSION SCRUTINY In contrast to the ‘whole picture’ described by Salman Rushdie, the media attention that concussion is currently receiving resembles a series of ‘pixels’. Not only journalists but coaches, athletes, parents and even medical colleagues often appear to focus on only one facet of the intricate picture that makes up the composite concussion portrait. Examples of ‘pixels’ include computerised cognitive tests, Rugby’s pitch side suspected concussion assessment (PSCA) and chronic traumatic encephalopathy (CTE). Each of these topics is often scrutinised outside of the context of many other signiﬁcant aspects of the concussion picture. CTE is one of the SEM’s ‘hot topics’ and the concussion strategies incorporated in collision sport are under increased scrutiny; in this edition of BJSM we provide updates on both. THE CONCUSSION STATUS QUO Few other areas of clinical sports medicine have received as much systematic attention as concussion has in the last 12 years. Independent experts have summarised the published evidence following a review of the literature and critical discussion held in Zurich in November 2012. The medical community has embraced concussion understanding and the protocols deﬁned by the 2013 Concussion in Sport Consensus Statement.1 The Concussion in Sport Consensus Statement is a document of signiﬁcant gravitas because it captures the systematic NIH consensus format, which is inclusive of scientists and clinicians constituting more than just expert opinion. The proto-col consists of ▸ Predeﬁning a group of key questions; ▸ Identifying a body of relevant literature; ▸ Two days of presentations by experts; ▸ A third day of discussion and debate in closed session by an expert panel; ▸ The drafting of a document circulated among the panel; ▸ A strategy to translate this knowledge. This logical developmental progression means that the 2013 Concussion in Sport Consensus Document1 should be our current reference point. RECURRING ZURICH THEMES Certain tenets have remained consistent and indeed strengthened through all four concussion consensus documents.1–4 ▸ The clinical presentation and assessment of concussions are multifaceted;  ▸ Symptoms and signs evolve and resolve over an undetermined period of time requiring serial and repeated assessments;  ▸ Certain cohorts, most notably children5 and athletes with ‘modifying’ characteristics,6 require a more conservative approach; ▸No player suspected of suffering a concussion should return to play that day;  ▸ The return-to-play decision is a clinical one best made by medical doctors familiar with consensus protocol. These are key themes and indispensable clinical features that frame every concussion ‘picture’. The consensus statements and other pragmatic guidelines,78 familiar to an expanding cohort of concussion experts, map out a structured approach based on the evidence at hand. A less comprehensive view based on only one aspect of the process may be distorting. CHRONIC TRAUMATIC ENCEPHALOPATHY The histological evidence for a degenerative neurological condition in certain athletes who have participated in collision sports appears convincing. The astrocytic, neuro-ﬁbrillary and neuritic changes are deﬁned, as well as the pattern of τ protein deposition have been described as a neuropathologycally distinct tauopathy.9 The existence of CTE in historical and modern ‘gladiators’ has been well elucidated and indeed classiﬁed by Gardner et al10 in their article in this edition of BJSM. What is tempting is to assume a reductionist approach that directly links all collisions in all contact sports with the development of long-term degenerative brain disease. While CTE may be well deﬁned pathologically and some association with sport has been identiﬁed—it still needs a signiﬁcant amount of work to understand who is at risk and why. Moreover, and Tator expands on this well, too many questions remain before we can ﬁll the aetiological chasm that exists between contact sports participation and CTE. These include the clarity regarding the number of blows, the effects of subclinical impact, the inﬂuence of other noxious inﬂuences on the brain, potential under-lying genetic susceptibility and speciﬁcity of such histological changes to sport. In literally focusing the histopathologist’s microscope on the CTE slide, what is magniﬁed is only one pixel which should not distort the entire concussion picture. What is clear is that, while more scientiﬁc and clinical facts emerge, a conservative approach to cases of concussion remains prudent. RUGBY—LEADING … AND LEARNING FROM OTHER CODES Rugby Union’s PSCA referred to in two of this issue’s papers—is currently a ‘pixel’ under scrutiny. PSCA is a screening tool allowing a team and the sideline doctors 5 min to take a player off the ﬁeld and make a call as to whether he/she has suffered a suspected concussion and should be removed from the game permanently. The key concepts to understanding PSCA are that it: ▸ Is only a triage support ‘tool’ and part of an expanded concussion management strategy; ▸ Is a multimodal support mechanism developed for doctors at the elite level of Rugby to assist with the assessment of a player who has a head injury where the diagnosis is not immediately apparent; ▸ Has been developed for a ‘replacement’ sport recognising that its introduction should not undermine the fabric of the game and it should not be open to tactical manipulation. ▸ Recognised that PSCA is not perfect but currently there is no perfect tool available. Raftery11 clearly explains that PSCA evolves from Zurich’s guidelines and is only one aspect of Rugby’s concussion ‘picture’ which includes a prevention strategy (law changes and enforcement, conditioning, etc), education and aware-ness campaigns for medics and laymen, an expanded concussion management proto-col and research support. It refers directly to Zurich 2012 in being multimodal (memory recall, symptom analysis, clinical and balance evaluation) and is incomplete without the serial follow-ups (based on the SCAT3) which are speciﬁcally prescribed in every case of suspected Rugby concussion. There has been a tendency to judge Rugby’s concussion stance on PSCA (and its implementation) alone. While Rugby may be leading the concept of additional sideline assessment time, it too can learn from other codes that incorporate, for instance, video surveillance. As with other sports, it is perhaps not the protocols that are at fault, but their implementation, a theme that has previously been highlighted in concussion literature.12 13 SOCIAL MEDIA MAY IMPROVE IMPLEMENTATION AND CREATE CLARITY What is needed in all sports is to pull the pixels together into a ﬂowing, plasma-quality picture that encapsulates the context of every concussion injury. The challenge in effective implementation is to have law makers, administrators, coaches, referees and players as well as medical staff all understanding that it is NOT acceptable to play while any of the clinic-ally determined parameters have yet to be fulﬁlled. How can we constructively harness the heightened mindfulness of concussion albeit as a result of sometimes pixelated and distorted media sources? Intensiﬁed public awareness channelled appropriately especially when combined with formal injury intervention programmes such as BokSmart14 and Rugby Smart may convey the reality that the beneﬁts and risks of contact and collision sports are acknowledged and being constructively addressed with resultant reduced injury rates. To this end, social media may be an important ally. In their various guises, social media have been shown to be immensely powerful tools in sports and exercise medicine.15 16 A constructive and deliberate strategy using many social media tools at our disposal may be a poignant strategy for sporting bodies and the Concussion in Sport Group to adopt in a systematic and rewarding manner. CONCLUSION: IMPLEMENTING EFFECTIVELY Medical doctors with an understanding of the evolution of concussion knowledge as well as the research horizon remain in the best position not only to assess and manage the concussed athletes but also to disseminate the information required to facilitate a global implementation of con-sensus protocols. Using only a single tool or drawing conclusions from seeing only one perceptible aspect of concussion management creates a distorted, ‘pixelated’ image. Similarly neither the clinicians nor the media should react to only one aspect of a player’s presentation. Following Zurich’s guidelines, better implementation and greater, consistent dissemination should be the areas of emphasis. This will allow the concussion ‘picture’ to look more like that on an HD ‘plasma’ rather than the isolated ‘pixels’ that have been the focus of so much attention. As doctors, we need to lead in management and broader implementation of the best guidelines we have—Zurich 2012. Social media may be an essential ally in conveying the ‘whole picture’. Contributors JSP and MM contributed towards the content and reviewing of the article. JSP planned the outline and theme, JSP was responsible for submitting the article. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. REFERENCES 1 McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–8. 2 Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the ﬁrst International Conference on Concussion in Sport, Vienna 2001. Br J Sports Med 2002;36:6–136. 3 McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196–204. 4 McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009;43:i76–84. 5 Davis GA, Purcell LK. The evaluation and management of concussion differs in young children. Br J Sports Med 2014;48:98–101. 6 Makdissi M, Davis G, Jordan B, et al. Revisiting the modiﬁers: how should the evaluation and management of acute concussions differ in speciﬁc groups? Br J Sports Med 2013;47:314–20. 7 http://www.acsm.org/access-public-information/team-physician-consensus-conference-statements (accessed 13 Nov 2013). 8 http://www.amssm.org/Content/pdf%20ﬁles/2012_ConcussionPositionStmt.pdf (accessed 13 Nov 2013). 9 Mckee AC, Cantu R, Nowinski C, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. J Neuropathol Exp Neurol 2009;68:709–35. 10 Gardner A, Iverson GL, McCrory P. Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med 2014;48:84–90. 11 Raftery M. Concussion and chronic traumatic encephalopathy: International Rugby Board’s response. Br J Sports Med 2014;48:79–80. 12 Finch CF, McCrory P, Ewing TM, et al. Concussion guidelines need to move from only expert content to also include implementation and dissemination strategies. Br J Sports Med 2013;47: 12–14. 13 Patricios JS, Collins RM, Roberts C. Zurich 2012: our cohort of ‘concussionologists’—conveying consensus. Br J Sports Med 2013;47:9–11. 14 Viljoen W, Patricios J. BokSmart—implementing a National Rugby Safety Programme. Br J Sports Med 2012;46:692–3. 15 Verhagen E, Bower C, Khan KM. How BJSM embraces the power of social media to disseminate research. Br J Sports Med Published Online First: 24 September 2013 doi:10.1136/bjsports-2013-092780. 16 Williams D, Sullivan SJ, Schneiders AG, et al. Big hits on the small screen: an evaluation of concussion-related videos on YouTube. Br J Sports Med 2014;48:107–111.  

The sports concussion picture : fewer 'pixels', more HD

https://repository.up.ac.za/bitstream/2263/42042/1/Patricios_Sports_2014.pdf

The sports concussion picture : fewer 'pixels', more HD

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